Version 1

NHS Leeds West CCG

Pharmacy First Self Care Service

Evaluation

2nd July 2015 – 16th February 2016

Anonymised Report

Produced by Dr Rachel Urban, Research and Evaluation Manager, Community Pharmacy West Yorkshire

1

SUMMARY OF EVALUATION AND RECOMMENDATIONS

Pharmacy First was introduced in July 2015 within 73 pharmacies which serve patients in NHS Leeds West

CCG. The service supports patients to self-care through the provision of advice, printed information and,

where necessary, the supply of medication from a defined formulary by the pharmacist. All patients

registered with a GP within Leeds West can be signposted to Pharmacy First. The Pharmacy First service

is only available to those exempt from prescription charges, to whom medication is supplied free of

charge. Patients attending the pharmacy who are not exempt from prescription charges can access free

advice under the community pharmacy essential service - self-care and can be offered the purchase of a

medicine. The cost of all medicines for conditions included within Pharmacy First is less than the current

prescription charge.

Overall, in the first 7 months, Pharmacy First in Leeds West has delivered a high number of consultations,

however when weighted for population and social deprivation the numbers delivered were lower than

other areas. Most patients who accessed Pharmacy First were under 10 years old, with approximately

half being under 5 years. The majority of patients were treated for fever without other viral symptoms

with analgesia/ antipyretic medication being the most common medication supplied. This is different to

other areas where viral symptoms were most common. The cost for medication was low (per patient

£1.77 and per item £1.43). Including the service fee of £4.50 this equates to an average consultation cost

per patient of £6.27 (exc VAT). This is similar other evaluated Pharmacy First Schemes in West Yorkshire.

The feedback from patients was positive with most patients indicating that they would be willing to re-

use the service and would recommend it to others. The variation of number of patients consulting the

self-care service per pharmacy and practice is positively skewed, with the majority of patients visiting a

small number of pharmacies and being from a small number of practices. It is unclear whether this is due

to increased pharmacy or GP practice promotion of the service in these areas, whether these practices

have a higher rate of minor ailment consultations or some other reason, for example, levels of deprivation.

Feedback from GP practice staff and pharmacy staff was mixed with some commenting that the service

had improved access, and working relationships between practice staff and pharmacy staff and others

feeling that further work to improve understanding and engagement was needed. Staff suggested the

service could be further improved through increased promotion and extension of the current formulary.

Feedback also highlighted that working relationships between some pharmacies and general practices

could be enhanced.

A number of further actions could be taken improve the success of the service. These are outlined in the

summary of recommendations below.

2

RECOMMENDATIONS

Encourage increased engagement and liaison and communication between general practice and

pharmacies to improve joint understanding, resolve issues and increase uptake

Consider further ways to increase promotion of the service by GP practice staff to ensure

appropriate use and referral

Work with GP practices to ensure that Pharmacy First is embedded into their triage systems and

patient pathways

Continue to work with NHS111 to ensure Pharmacy First is an integral part of the urgent care

provision in the CCG area.

Review list of conditions and formulary with the Pharmacy First project group and if agreed devise

a further business case to expand the service to include further conditions

Promote increased recording of patient access to Pharmacy First on GP electronic health record.

Produce a summary document which helps patients understand how Pharmacy First works

Provide increased education and information to practice staff to improve appropriateness of

referrals to Pharmacy First

Plot practice IMD score against use per 1000 population to determine whether there is a

correlation. This may give an indication of those practices which would benefit from increased

activity

Explore the reasons why the number of cough and antibiotic leaflets is lower than the number of

patients eligible and reiterate the importance of the provision of printed information.

Work with commissioners to ensure a single common ailments service, rather than the current

split system in Leeds West

Explore the reasons why fever without viral symptoms was the most common presenting

complaint in comparison with other areas

1 INTRODUCTION

Pharmacy self-care schemes or minor ailment schemes (MASs) are commissioned to promote self-care

through a consultation with the pharmacist.1,2,3 They have the opportunity to provide treatment and

symptomatic relief, where appropriate, using a defined formulary for self-limiting and easily treatable

conditions that do not require medical intervention. Approximately 30% of consultations within general

practice are for minor ailments of which approximately 60% can be treated by a community pharmacist.1

A systematic review published in 2013 has shown that MASs provide a suitable alternative to GP

consultation and decrease re-consultation rates in GP practices, with most patients reporting complete

resolution of symptoms.2 This leads to a decrease in GP prescribing costs and the number of consultations

for minor ailments.2

In July 2015, Pharmacy First was commissioned by NHS Leeds West CCG, following the success of

Pharmacy First in Bradford City CCG which commenced in January 2014.3 It provides Leeds West patients

with rapid access to a pharmacist for self-care advice and, where necessary, medication from a defined

3

formulary for a range of minor ailments. The ultimate aim is to provide a more appropriate alternative to

the use of general practice or other health care providers (e.g. A&E, Out of Hours Urgent Care) for minor

ailments, potentially releasing capacity within general practice through the provision of a more cost-

effective service. The service is aimed at patients who use GP or out of hours services when they have a

minor ailment rather than self-care or purchasing medicines over-the-counter (OTC). It is hoped that this

service will change patient behaviours, educating and assisting patients in how to access self-care and the

appropriate use of healthcare services.

The service supports patients to self-care through the provision of advice, printed information and, where

necessary, supplied medication from a defined formulary by the pharmacist. All patients registered with

a GP within Leeds West can be signposted to Pharmacy First. The Pharmacy First service is only available

to those exempt from prescription charges, to whom medication is supplied free of charge. Patients

attending the pharmacy who are not exempt from prescription charges can access free advice under the

community pharmacy essential service (self-care and can be offered the purchase of a medicine. The cost

of all medicines for conditions included within Pharmacy First is less than the current prescription charge

(see service specification and service guide for further details accessed at www.cpwy.org ).

2 SERVICE

Pharmacy First was introduced at the beginning of July 2015 within 73 pharmacies which serve patients

within NHS Leeds West CCG. The presenting patient must currently be registered with a GP within Leeds

West and be suffering from an ailment which is included in the service.

The following conditions can be managed within the Pharmacy First service:

Cough

Cold

Earache

Sore throat

Threadworms

Teething

Athletes foot

Thrush

Hay fever

Fever

Sprains and strains

Blocked nose

These conditions can be treated using medication listed in the Pharmacy First formulary (see table 1):

Table 1 Pharmacy First Formulary

Formulary

Beclometasone 50 mcg nasal spray (200 sprays)

Cetirizine solution 5mg/5ml (200ml) SF

Cetrizine 10mg tablets (30)

Chlorphenamine syrup (150 ml) SF

Chlorphenamine tablets 4 mg (30)

Clotrimazole 500mg pessary (1)

4

Formulary

Clotrimazole cream 1% (20g)

Ephedrine 0.5% nasal drops (10ml)

Fluconazole 150 mg cap (1)

Ibuprofen suspension 100mg/5ml (100ml) SF

Ibuprofen tablets 200mg (24)

Ibuprofen tablets 400mg (24)

Lidocaine alone or with Cetalkonium /Cetylpyridiniumteething gel (10/15g)

Loratadine syrup 5mg/5ml (100ml)

Loratadine 10mg tablets (30)

Mebendazole suspension (30ml)

Mebendazole 100mg tablet (1)

Mebendazole 100mg tablet (4)

Miconazole 2% cream (30g)

Paracetamol 500 mg tablets (32)

Paracetamol soluble tabs 500mg (24)

Paracetamol Susp SF 120 mg / 5 ml (100ml) SF

Paracetamol Susp SF 250 mg / 5 ml (100ml) SF

Sodium chloride 0.9% nasal drops (10ml)

Pharmacists can supply any brand of product as long as the active ingredients are the same and pack size is at least

the size specified above (i.e. larger packs can be supplied). The products supplied must not be POM packs and

each product must be supplied with a corresponding Patient Information Leaflet.

The formulary products can be used for any of their licensed indications at licensed doses and therefore

pharmacists can also treat: self-limiting pain, fungal infections (Ringworm, Candida intertrigo) and headache (this

list is not exhaustive) if an eligible patient presents with these symptoms or conditions.

The pharmacist assesses the patient’s condition using a structured approach to responding to symptoms (see

table 2), then provides information and where appropriate medication according to the formulary (see table 1).

The Leeds West Pharmacy First service does not include any cough preparations within their formulary. The

rationale being there is no good evidence from trials that cough medicines are effective or reduce the severity /

length of a cough. Cough medicines are considered to be drugs of limited clinical value and GPs are encouraged

not to prescribe them. Additionally the MHRA has stated that cough medicines containing antihistamines, cough

suppressants, expectorants, or decongestants should be avoided in children under 6. Patients presenting with a

cough are managed by the provision of information (oral and printed) regarding the management of coughs.

5

Table 2 Summary of assessment and provision of advice

Assessment Provision of advice

The pharmacist identifies:

Nature and duration of symptoms

Concurrent medication and medical conditions

Exclusion of any serious disease / alarm / red flag symptoms

If the patient is pregnant/ breastfeeding

If any medication has already been supplied / taken for the ailment

Symptoms

The pharmacist provides advice on:

Expected symptoms

What is normal

Probable duration of symptoms

Self-care messages: What patients can do for themselves to help manage the ailment

Where (and when) to go for further advice / treatment if necessary e.g. If the cough lasts for more than 3 weeks visit your GP

Antibiotic stewardship message

Data from each consultation is recorded on PharmOutcomes® (a data capture system which pharmacy use to

claim for service provision).

LEEDS MINOR AILMENTS There is currently an alternative scheme running within Leeds for common ailments, commissioned by NHS

England. This was established prior to the reformation of the NHS in 2013. Management of the scheme passed

to NHS England during the establishment of CCGs. This evaluation reviews data from the Leeds Minor Ailment

Scheme and the impact it may have on the scheme.

These two schemes run in parallel, alongside each other. Pharmacies have been advised to assume that all

patients presenting in the pharmacy have come for self-care advice and purchase of over-the-counter medicines.

If through discussion with the patient it is clear that they have been referred from the GP practice then Pharmacy

First should be provided (as long as patient meets eligibility criteria). If the patient has not been referred by the

practice and the pharmacy feel that a free supply of medicines is appropriate to prevent the patient presenting

at the GP surgery then the NHS England minor ailment service should be used.

The two schemes are similar however there are a number of significant differences (see table 3).

Table 3 Comparison of Pharmacy First and Leeds Minor Ailments

Pharmacy First Leeds Minor Ailments

Consultation Payment - £4.50 Consultation Payment - £3.00

Standardised framework which provides consistent consultations

No structured consultation framework

Detailed service specification and guide Lack of detailed service specification and guide

Self-Care messages are key rather than medicines supply

Focuses on medicines supply rather than self-care

List of ailments more limited than Leeds Minor Ailments scheme

Wider list of ailments covered than Pharmacy First

Consultation backed by printed information No requirement to provide printed information

6

GPs are informed of patients attendance for consultation

Patients GP not informed of consultation

Activity data readily available through PharmOutcomes

Activity data not easily available

Pharmacies receive activity and benchmarking data Pharmacies do not receive activity and benchmarking data

Only evidence based medicines are included on the formulary

Formulary contains medicines with poor evidence base

Promotional material and guidance available No promotional material available

Regular oversight by Pharmacy First Project Group No regular oversight

3 METHOD OF EVALUATION

All data inputted on to PharmOutcomes was evaluated from 2nd July 2015 – 16th February 2016. This included

patient feedback questions asked at the end of each Pharmacy First consultation. Data was extracted into Excel

and reported using descriptive statistics. Activity data from NHS England for Leeds Minor Ailments Scheme was

also analysed and reported using descriptive statistics. Questionnaires were devised to gain opinions from GP

practice staff and pharmacy staff on Pharmacy First. The GP questionnaire was distributed via SurveyMonkey®

(to GPs, Practice Nurses and Practice Managers) and the pharmacy staff questionnaire using both paper-based

questionnaires and SurveyMonkey®.

4 RESULTS

Pharmacy First

Overview

Over the seven month evaluation period, 39 community pharmacies, conducted a total of 921 consultations (73

pharmacies are accredited to deliver the service). The range of consultations per pharmacy varied from 1 to 179

with a mean of 23.6 consultations per pharmacy and a median of 9 consultations per pharmacy (see figure 1).

Of the 921 consultations, 369 (40.1%) were delivered in a private consultation room, the rest in a private area of

the pharmacy (552/921 – 59.9%).

Patient Demographics

Out of 921 consultations, 508 (55.2%) were female and 413 (44.8%) male. Nearly 70% (66.2% - 610/921) of the

patients seen were under 10 years old (see figure 2), with the majority of those being under 5 years old (50.4%,

464/921). Thus, the majority were exempt from prescription charges due to being under 16 (see figure 3). Most

patients described themselves as White – British (77.1% - 710/921) with Asian or Asian British – Pakistani being

next highest (11.5% - 106/921) (see figure 4). Twenty-five per cent (228/921) of patients accessing the service

lived within LS13, with a large proportions from WF3, LS28, LS6 and LS12. (see figure 5).

7

Practices

The patients using the service were registered at 37 practices (see figure 6). The mean number of patient visits

per GP practice was 24.9 visits and the median 6 visits (range 1-84 visits). The range per 1000 practice population

was 0.14 – 12.61 consultations with mean 2.3 consultations and median 0.91 consultations (see figure 7).

Version 1

Figure 1 Percentage of consultations delivered per pharmacy

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Version 1

Figure 2 Age of patients using Pharmacy First

Figure 3 Exemption status of patients using Pharmacy First

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10

Figure 4 Ethnicity of Patients using Pharmacy First

Figure 5 Post code area of patients using Pharmacy First

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Figure 6 Registered practice of patients using Pharmacy First

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Version 1

Comparison of consultations delivered per Pharmacy First area in the last six months

Comparison of absolute numbers of consultations shows that NHS Bradford City CCG (the longest established

scheme) delivered the most consultations in the six months between September 2015 and February 2016 with

NHS Leeds West CCG the third highest (see figure 8), however, when weighted for population size and social

deprivation Bradford City still remains the highest with NHS Leeds West CCG the lowest (see figure 9).

Figure 8 Number of consultations delivered per Pharmacy First area in the last 6 months (September 2015 –

February 2016)

Figure 9 Number of consultations per CCG area weighted for population and social deprivation in the last 6

months (September 2015 – February 2016)

0

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The Consultation

Figure 10 Distribution of patient consultations throughout the week

Figure 11 Distribution of patient consultations throughout day Monday to Sunday

The number of consultations peaked mid-week with fewer on the weekend. The peak times of day for

consultations were mid-morning and mid-afternoon, with 61 consultations (6.6%) being on a Saturday or Sunday

and 66 (7.2 %) consultations being out of hours on a weekday (before 8am or after 6pm); total 13.8% (127/921)

out of hours (see figures 10 & 11).

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Time of Day

15

Patients presented at the pharmacy with a total of 28 different symptoms. Forty (4.3 %) patients presented with

two different presenting complaints. The majority of patients presented at the pharmacy with fever without viral

symptoms (see figure 12). Ninety-nine per cent (912/921) of patients were treated in the pharmacy and did not

require any onward referral to other services; the remainder were referred onward (see table 4).

Table 4 Onward referral to other health care providers

Referral Number of Patients

Percentage Patients

None required 912 99.0%

In hours usual care to GP 7 0.8%

Urgent (via telephone) to NHS 111 1 0.1%

Dentist 1 0.1%

Version 1

Figure 12 Presenting Symptoms treated as part of Pharmacy First

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Indication

Version 1

Supply of Medication

A total of 1139 medications were supplied to patients. The range of medicines supplied varied from 0 to 3

medicines per patient with most people receiving one medicine (74.8%, 689/921) (see figure 13). Most

commonly patients were supplied with an analgesic/antipyretic (see figure 14). The cost per patient was £1.77

(£2.13 inc VAT) and cost per item was £1.43 (£1.72 inc VAT). Including the service fee of £4.50 this equates to

an average consultation cost per patient of £6.27 (£6.63 inc VAT). The total cost of the service (consultation fee

+ cost of medication) for the first ten months was £5778.62 (£6105.44 inc VAT) (assuming all consultations were

claimed).

Figure 13 Number of medicines supplied per patient

0%

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0 1 2 3

Pat

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Number of Medicines

18

Figure 14 Medication provided to the patient following consultation

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ts

Medication

19

Figure 15 Leaflet provided to patient during consultation

All patients were provided with verbal advice during the consultation. This varied depending on the patient’s

presenting complaint/symptoms. Only 61.3% (565/ 921) of patients were provided with written information or

referred to a website to support their consultation. The majority of those patients who were provided with

written information from patient.co.uk (see figure 15). A small number of patients received ‘get better without

antibiotics’ information (9.8%, 90/921) and information on managing cough (11.3%, 104/921). This is lower than

the number of patients which were eligible to receive a cough or antibiotic leaflet.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

NH

S C

ho

ice

s In

form

atio

nP

resc

rip

tio

n

Pri

nte

d in

form

atio

n n

ot

app

rop

riat

e /

su

itab

le f

or

pat

ien

t

Pat

ien

t.co

.uk

Hea

lth

info

rmat

ion

leaf

let

PIL

Ph

arm

acy

Firs

t Le

afle

ts

Pat

ien

ts

Leaflet

20

Patient Experience Captured on PharmOutcomes®

Figure 16 Action the patient would have taken if Pharmacy First was not available

The majority of patients (83.8%, 772/921) stated they would have used the GP had they not accessed the service

(see figure 16). Using this information and assuming the average GP consultation is 10 minutes5 this has released

128 hours 40 minutes practice time across 37 practices (see table 5). The mean time released per practice was 3

hours 29 minutes, with a median of 40 minutes. Using a fee of £576 for A&E attendance the overall savings from

the service for the first eight months is £456.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Go

ne

to

GP

Bo

ugh

t p

rod

uct

Go

ne

to

Acc

iden

t an

d E

mer

gen

cy

Cal

led

NH

S 1

11

Co

nta

cted

Ou

t-O

f-H

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rs G

P

Pat

ien

t d

id n

ot

answ

er

qu

est

ion

Do

ne

no

thin

g

Oth

er

Pat

ien

ts

Action

21

Table 5 Number of hours released per practice

GP Practice Hours Min

A 28 30

B 21 30

C 18 40

D 12 10

E 9 40

G 6 0

J 4 0

I 3 0

K 2 40

F 2 30

H 2 10

M 2 10

L 2 0

O 2 0

Q 1 10

P 1 10

N 1 10

R 0 50

T 0 40

S 0 40

X 0 40

U 0 40

BB 0 30

Z 0 30

W 0 30

AA 0 30

Y 0 50

DD 0 20

GG 0 20

CC 0 20

II 0 10

JJ 0 10

EE 0 10

HH 0 10

V 0 10

Total 128 40

22

Figure 17 Method through which the patient found out about the service

Most patients knew about the service because they had been informed by the pharmacy (33.1%, 305/921); many

had also indicated that they had used it before (31.4%, 290/921) (see figure 17). It is unclear whether the patient

was referring to the pharmacy, Pharmacy first or a previous minor ailments scheme. Over 95% of patients

(96.3%, 887/921) stated that they would recommend the service to a friend, the remainder either did not

respond (1.8%, 17/921), were not sure (1.2%, 11/921) or stated that they would not use it again (0.7%, 6/921).

Most patients felt that Pharmacy First had increased their confidence to self-care without seeing a doctor (95.3%,

878/921), with 97.0% (893/921) saying that they would use Pharmacy First next time they needed advice.

Leeds Minor Ailments Scheme

Over the same seven month evaluation period, 5 community pharmacies, conducted a total of 2199

consultations under the Leeds Minor Ailments Scheme. The range of consultations per pharmacy varied from 31

to 1686 with a mean of 439.8 consultations per pharmacy and a median of 152 consultations per pharmacy.

Adding these consultations to the 921 consultations delivered through Pharmacy First gives a total of 3120

consultations over the 7 month evaluation period.

0%

5%

10%

15%

20%

25%

30%

35%

Info

rmed

by

ph

arm

acy

Use

d b

efo

re

Info

rmed

by

GP

su

rger

y

Po

ster

Fam

ily/

frie

nd

Pat

ien

t d

id n

ot

answ

er

qu

est

ion

Face

bo

ok

Info

rmed

by

NH

S 1

11

CC

G

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ou

th

Den

tist

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Med

ia

On

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Wo

rk

Ho

spit

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Pat

ien

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Method

23

GP Practice Staff Opinion

A total of twenty-one GP practice staff responded to the questionnaire. Nine respondents suggested that there

should be additional conditions included in Pharmacy First (see table 6). Three also suggested further

medications to be included in the formulary (see table 7).

Table 6 Conditions to add to Pharmacy First suggested by GP Practice Staff

Condition Number of respondents

Verrucae and Warts 3

Head lice 2

Conjunctivitis 2

Eczema/ contact dermatitis 1

Nappy rash 1

Haemorrhoids 1

Uncomplicated UTIs 1

Diarrhoea and vomiting 1

EHC 1

Constipation 1

Sinusitis 1

Cold Sores 1

Verrucae/ Warts 1

Dandruff/ itchy scalp 1

Table 7 Medications to add to the Pharmacy First formulary suggested by GP Practice Staff

Medication Number of respondents

Head Lice treatment 1

Head lice combs 1

Eye drops for infection 1

Rehydration sachets 1

Saline nasal drops 1

Haemorrhoid treatment 1

Constipation treatment 1

Levonorgestrel and ulipristal (EHC) 1

Wart / Verrruca treatment 1

Ear drops for infection 1

Most practice staff (16/20) felt they were well informed about the service before it started. Eighteen

respondents stated that they had promoted the service within the GP practice for example through the display

of promotional material, information on the practice website and answerphone messages; two practices had

not actively promoted the service. Twelve members of these staff members felt that they did not need

anything further to help them to promote the service. Conversely, three members of practice staff felt that

24

they could promote Pharmacy First better if neighbouring pharmacies were better engaged and were providing

the service. Staff felt that patients could be better informed through increased advertising and more publicity

including the use of television, radio and newspaper advertising, as well as promotion by the community

pharmacy themselves. One practice felt that further information to support reception staff with referral

would assist promotion of the service.

The resources were well received by practice staff with most liking the posters and credit cards (see figure 18).

Figure 18 Resources found useful by GP practice staff

Three members of staff reported that their practice routinely recorded that the patient had used Pharmacy

First on the practice electronic health record. Fourteen specified that they did not, with ten adding that they

had not received any notifications. It is unclear whether this is because none of their patients have used

Pharmacy First or they have not received the notifications or are unaware how they are received.

No-one felt that Pharmacy First had decreased the number of patients attending the GP practice, with one

member of staff adding:

‘Patient's [are] still quite apprehensive about not seeing a GP.’

Another commented on the lack of awareness by patients:

‘Despite advertising the service and promoting it patients still seem to present to the practice first’

Three respondents felt it had improved relations between the practice and the pharmacy with one adding that

they were now ‘working more in partnership’, others felt there had been no improvement with one feeling it

had made things worse:

‘[Pharmacy First has] made no difference at all. If anything it has created more problems because

patients are angry at being sent to pharmacy then refused meds even though it is meds that are

available on pharmacy first’

Fourteen respondents felt that Pharmacy First was worthwhile as it educated patients, promoted self-care and

reduced demand in GP practice. Five felt that it was not worthwhile, mainly due to patients demanding to see

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pharmacy FirstPosters

Pharmacy First CreditCards

GP guide to PharmacyFirst

Pharmacy First – A Summary for GPs

(Service summary on a page)

Other (please specify)

REs

po

nd

ents

Resource

25

a GP and feeling ‘fobbed off’ if they are sent to the pharmacy. It was acknowledged that patient behaviour

needed to change if the service was to be a success. One member of staff added that increased leadership to

embed the service and improve practice –pharmacy liaison and engagement would be useful

‘The reality is there needs to be more leadership from someone on this. Someone could facilitate a

meeting/training session for the GP surgery staff to do together with local pharmacies’

GP staff still felt that more needed to be done to embed the service into routine practice, acknowledging that

this will take time and the service needed expanding to cover more ailments.

‘Will take time to change behaviour and patients to understand the role of the pharmacy in treatment

of minor illness.’

‘Increase conditions treated and medicines given. More emphasis in out of hours [OOH] care.

Integration in Primary care/ OOH service/ A&E.

Overall there is mixed opinion from GP practice staff on the service with some embracing it and others

sceptical about its role and success. This has been contributed to by the lack of participation and engagement

by some pharmacies.

‘We were all very excited about this service as it is a fantastic idea but a massive shame that the

pharmacies have totally let the service fail’

Better communication with Primary care and collaboration [is needed] rather than competition’

Pharmacist Opinion

Twenty-four members of pharmacy staff completed the feedback survey. Twenty-three had provided

consultations from their pharmacy; one had not had a request but provided the NHS England Minor Ailments

Scheme. Fifteen suggested further medications which should be included within Pharmacy First (see table 8).

Table 8 Medications to add to the Pharmacy First formulary suggested by pharmacy staff

Medication Number of Respondents

Chloramphenicol drops / ointment 9

Head lice treatment 7

Hydrocortisone cream/ointment 5

Cough preparations 1

Antacids 1

Infacol 1

Clotrimazole cream 1

Wart treatment 1

26

Figure 18 Resources found useful by pharmacy staff

Most found NHS choices useful as a patient information resource, as well as patient.co.uk and the Pharmacy

First consultation record form (see figure 19). Seven commented that they felt there were sufficient resources.

One had produced a display within the pharmacy and another an information leaflet explaining the service in

more detail.

Suggestions to make the service easier to deliver included better promotion and understanding by general

practice, advertising, a condensed consultation form, improved understanding of declaration of competence

and more promotional material.

The majority of respondents (17) felt the information received prior to starting the service prepared them

sufficiently to conduct the service and that the support received from Community Pharmacy West Yorkshire

was helpful (see figure 19).

‘I liked the fact you could contact the team regarding the service and always received a prompt reply

with good advice and guidance’

Two respondents mentioned being confused at the beginning due to the existing minor ailment service running

concurrently with Pharmacy First.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

NH

S C

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s

Pat

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.uk

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Ph

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Firs

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Ph

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ho

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Ph

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ice

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Ph

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Firs

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)

NH

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Self

Car

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Fac

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Self

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Wh

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Cre

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Win

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27

Figure 20 Helpfulness of Support received from CPWY

PharmOutcomes® was thought to be easy and straight forward to use in most cases (18/22). Three

respondents mentioned that despite it being straight forward it was time consuming.

Seven respondents felt that Pharmacy First had improved relationships with their GP practice including

communication. One respondent added:

‘[We have] definitely had more referrals across and used my consultation room more. …… most patients

just needed advice not necessary any treatment.

And another:

‘ The local surgery is encouraging patients to use the service before making appointments’

The remainder felt that the GP practices could be more engaged and better understand the service:

‘GP practices do refer patients but many of times it’s been for things that are not on the service, which

leaves them annoyed.’

‘Most GP's don’t know of the service or if they do they don't know what medication is on the formulary.

Also on several occasions the GP's have sent patients asking for medication that isn’t on the list.’

The majority of pharmacy staff (12/21) felt that their relationship with the patients had improved with the patient putting more trust and confidence in the pharmacist.

‘More come to us first than the GP. They also find we have more time to listen to them and try and resolve the queries.’ ‘As the service has progressed patients are coming back asking for the service and recommending it to friends.’

0%

10%

20%

30%

40%

50%

60%

Very Unhelpful Unhelpful Not sure Helpful Very Helpful

Res

po

nd

ents

Level of Helpfulness

28

‘Customers are confident in the pharmacy service. Knowing they can get certain meds without seeing a GP because they don't pay prescription charges has made us convenient’

Although some pharmacy staff felt that there were still some challenges which needed to be overcome:

‘They just think they can get free medicines without having the need of a consultation and they are not impressed if you do not supply what they are asking for, mainly paracetamol.’ ‘The service is unfortunately not wide-ranging enough and it is difficult to advertise and make any real

difference as we're not allowed to tell patients it's a free service. We have only done about 20

consultations. That said it's a good idea for a service and it often takes years to change habits not

months.’

In the main, the pharmacy staff were pleased with the service but felt the service could be improved through

further advertising, increased understanding by GPs, reception staff and patients, and expanding the

formulary. Feedback also highlighted that working relationships between some pharmacies and general

practices could be significantly improved, it was unclear what action, if any, had been taken by either party to

resolve any issues experienced.

5 DISCUSSION

Over the first seven months, a number of consultations for minor ailments were delivered through Pharmacy First. The number of consultations for Pharmacy First is not as high as those seen in Bradford City, but higher than other areas offering a similar scheme.3, 4 When weighted for population size and social deprivation the uptake was the lowest. The lower uptake may be attributable to the pre-existing NHS Minor Ailments Scheme, lack of engagement with the service by GP practice, pharmacists or patients or some other reason. (NB The number of consultations per 1000 population is not as low If the minor ailment scheme consultations are added to the Pharmacy First consultations). Further work looking at ways to appropriately increase usage is needed. It would also be useful to look at practice IMD scores and plot against number of consultations per 1000 population to determine which GP practices may benefit most from the scheme.

The majority of patients seen were under 10 years old with over half of those being under 5 years. Most commonly patients were treated for fever without viral symptoms. This is in contrast to the findings within other neighbouring schemes. This difference needs exploring further to establish the reason for the difference. Approximately one in eight patients used the service in the-out of-hours period, when their usual GP would be closed.

Written information was provided to many patients, including ‘Get better without antibiotics leaflets’ and ‘Pharmacy First Cough Leaflets’ although more patients were eligible to receive these than actually received them. Exploration of the reasons for this and reiteration of the importance of provision of printed information is needed.

The cost for medication was low (per patient £1.77 and per item £1.43 exc VAT). This similar to other evaluated

Pharmacy First Schemes in West Yorkshire. Including the service fee of £4.50, this equates to an average

consultation cost per patient of £6.27 (£6.63 including VAT). This is lower than previous evaluated schemes

outside West Yorkshire and similar to other Pharmacy First services.2,3,4

29

The variation in number of patients consulting Pharmacy First per pharmacy and practice is positively skewed;

the majority of patients visiting a small number of pharmacies and being from a small number of practices.

Approximately only 50% of accredited pharmacies have delivered consultations for this service within NHS Leeds

West CCG. It is unclear whether this is due to pharmacy or GP practice promotion of the service in these areas,

whether these practices have a higher rate of minor ailment consultations or some other reason such as level of

deprivation. It would be useful to plot practice IMD score against number of Pharmacy First consultations per

1000 population.

A significantly large number of consultations for minor ailments are currently being delivered under the historical

Leeds Minor Ailments Scheme rather than through Pharmacy First. This may have affected the number of

consultations claimed through Pharmacy First. The historical Minor Ailments scheme has a number of

disadvantages in comparison to Pharmacy First, predominantly the lack of standardised consultation and lack of

focus on improving self-care. The presence of two different pathways/ split system also causes confusion for

both patients, pharmacies and other health care professionals. Despite these disadvantages, the Leeds Minor

Ailment scheme does have a wider formulary and range of conditions which can be treated. Commissioners

must work together to provide a single service which includes an increased range of conditions to ensure a

clearer pathway for patients with an appropriate range of conditions. This can be managed without additions to

the formulary where there is a poor evidence base for medication. This will be discussed together as part of an

overall review of the service.

Overall, there was positive feedback from patients, GP practice staff and pharmacy staff. Both practice staff and

pharmacy staff felt that the formulary needed expanding to increase the use and maximise the potential of the

scheme. There were some respondents who mentioned the paperwork being too onerous which was previously

mentioned in two other area evaluations. This also needs exploring further. Some pharmacies and GP practices

experienced improved relationships with each other; others expressed difficulties with communication and

engagement with the service on both sides. It is unclear the extent to which these practices have tried to resolve

their difficulties with each other and the mis-communications which have occurred. In addition, some GP

practices expressed lack of participation by some pharmacies, despite the high number of pharmacies accredited.

Practices and pharmacies should be supported to improve relationships and communication with each other to

increase the accuracy of referrals and smooth running of the service.

Limitations

Other studies have looked at the impact of minor ailment schemes on general practice prescribing for minor

ailments and also the number of re-consultation rates. It is not possible to evaluate this with current available

data, however the potential use of practice data could be explored for future evaluation of the service.

The GP time released was based on the patients specifying where they would have gone; this may differ from

where they may have gone had the service not been in place. The patient opinion data was collected by the

pharmacists providing the service which may have biased the results due to the patient not wanting to offend

the pharmacist.

30

6 CONCLUSIONS

Overall, in the first seven months, Pharmacy First has delivered a number of consultations which have been cost-

effective and embraced by the majority of patients. Further work to increase understanding, promotion and

engagement, plus build relationships between pharmacy and practice staff is needed to increase uptake. The

list of ailments and provision of two common ailment schemes within Leeds West must also be reviewed.

RECOMMENDATIONS

Encourage increased engagement and liaison and communication between general practice and

pharmacies to improve joint understanding, resolve issues and increase uptake

Consider further ways to increase promotion of the service by GP practice staff to ensure appropriate

use and referral

Work with GP practices to ensure that Pharmacy First is embedded into their triage systems and patient

pathways

Continue to work with NHS111 to ensure Pharmacy First is an integral part of the urgent care provision

in the CCG area.

Review list of conditions and formulary with the Pharmacy First project group and if agreed devise a

further business case to expand the service to include further conditions

Promote increased recording of patient access to Pharmacy First on GP electronic health record.

Produce a 1-page document which helps patients and practice staff to understand how Pharmacy First

works

Provide increased education and information to practice staff to improve appropriateness of referrals to

Pharmacy First

Plot practice IMD score against use per 1000 population to determine whether there is a correlation.

This may give an indication of those practices which would benefit from increased activity

Explore the reasons why the number of cough and antibiotic leaflets is lower than the number of patients

eligible and reiterate the importance of the provision of printed information.

Work with commissioners to ensure a single common ailments service, rather than the current split

system in Leeds West

Explore the reasons why fever without viral symptoms was the most common presenting complaint in

comparison with other areas

31

7 REFERENCES

1) Watson MC. Community Pharmacy Management of Minor Illness. MINA study Report. Final Report to

Pharmacy Research UK. 2014. Accessed at http://www.pharmacyresearchuk.org/waterway/wp-

content/uploads/2014/01/MINA-Study-Final-Report.pdf on 26th June 2014.

2) Paudyal V, Watson MC, Sach T, Porteous T, Bond CM, Wright DJ, Cleland J, Barton G, Holland R. Are

pharmacy-based minor ailment schemes a substitute for other service providers? A systematic review.

Br J Gen Pract. 2013; 63(612):e472-81.

3) Community Pharmacy West Yorkshire. NHS Bradford City CCG Self Care Service. Pharmacy First - 8

Month Evaluation. (2014) Accessed at http://www.cpwy.org/doc/795.pdf

4) Community Pharmacy West Yorkshire. NHS Airedale, Wharfedale and Craven CCG Self Care Service.

Pharmacy First - 10 Month Evaluation. (2014) Accessed at http://www.cpwy.org/doc/1056.pdf

5) Curtis L. Unit Costs of Health and Social Care2011. PSSRU. 2011. Accessed at

http://www.pssru.ac.uk/archive/pdf/uc/uc2011/uc2011.pdf on 26th June 2014.

6) National tariff payment system 2014/15. Annex 5A - National prices. Accessed at

https://www.gov.uk/government/publications/national-tariff-payment-system-2014-to-2015 on 26th

June 2014.

7) National Services Scotland (NHS). Prescribing & Medicines: Minor Ailments Service (MAS). Financial Year

2013/14. Information Services Division. Accessed at https://isdscotland.scot.nhs.uk/Health-

Topics/Prescribing-and-Medicines/Publications/2014-06-24/2014-06-24-Prescribing-

MinorAilmentsService-Report.pdf?12537783385 on 26th June 2014.